Low Risk of Neurological Recurrence while Awaiting Carotid Endarterectomy: Results From a Danish Multicentre Study.

OBJECTIVE: The risk of ipsilateral neurological recurrence (NR) was assessed in patients awaiting carotid endarterectomy (CEA) due to symptomatic carotid artery stenosis and whether current national guidelines of performing CEA within 14 days are adequate in present day practice. METHODS: This was a retrospective multicentre observational cohort study. Patients scheduled for CEA due to symptomatic carotid artery stenosis in a five year period, 1 January 2014 to 31 December 2018, from four centres were included. Data from the Danish Vascular Registry (www.karbase.dk), operative managing systems, and electronic medical records were reviewed. RESULTS: In total, 1 125 patients scheduled for CEA were included and 1 095 (97%) underwent the planned surgery. During a median delay from index event to CEA of 11 days (interquartile range 8-16 days), 40 patients (3.6%; 95% confidence interval [CI] 2.5%-5%) experienced a NR. One third were minor strokes (n = 12, 30%); half were transient ischaemic attacks (TIA) (n = 22, 55%); and amaurosis fugax accounted for 15% (n = 6). Twenty-six (2%) CEA procedures was cancelled, of which one was due to a disabling recurrent ischaemic event (aphasia). There were no deaths or major strokes in the waiting time for CEA. Best medical treatment (BMT) with platelet inhibitory or anticoagulation drugs and a statin was initiated in nearly all patients (98%) at first assessment. The overall 30 day risk of a post-operative major event (death or stroke) was (Kaplan-Meier [KM] estimate) 2.7% (95% CI 1.8-3.8), and not significantly correlated with the timing of surgery. Most (69%) occurred within the first three days. One, two, and three year mortality rate for CEA patients was (KM estimate) 4.8%, 7.8%, and 11.5% respectively. CONCLUSION: In symptomatic carotid artery stenosis patients awaiting CEA, very few NRs occurred within 14 days. Institution of immediate BMT in specialised TIA/stroke units followed by early, but not necessarily urgent, CEA is a reasonable course of action in patients with high grade symptomatic carotid artery stenosis.

The crucial role of gadolinium-enhanced MRI in a case of amaurosis fugax - a case report and literature review.

Optic perineuritis is the inflammation of the optic nerve sheath. This affliction can lead to visual field impairment and other signs and symptoms related to the orbital space, such as pain, disc edema, ophthalmoplegia, proptosis. However, not all patients present with such suggestive symptoms, requiring a thorough assessment. We report the case of a young male admitted to our hospital for recurrent episodes of monocular blindness. Amaurosis fugax is a well-known presentation of transient ischemic attacks (TIA) and it was ruled out. Gadolinium-enhanced MRI revealed a typical aspect of optic perineuritis. It was mandatory to consider all possible causes of secondary optic perineuritis as they all represent serious clinical conditions, even if the idiopathic form is more frequent. The clinical and paraclinical evaluation of the patient excluded an underlying disease and primary optic perineuritis was diagnosed. Corticosteroid therapy is usually curative and a course of methylprednisolone was initiated for our patient with good outcome. However, response to treatment is not diagnostic as both primary and secondary optic perineuritis are normally responsive, hence thorough differential diagnosis is necessary.

Transient visual loss in a 60-year-old man.

A 60-year-old man after 5 years of recurrent episodic amaurosis fugax, always resolving, experienced an incident of visual loss that was permanent. Computed tomography and magnetic resonance imaging were normal. Transesophageal echocardiogram and carotid duplex scan ruled out embolic sources from the heart and neck vessels. Blood tests for hypercoagulability found elevated APTT not correcting with 50:50 dilution with control serum, owing to the presence of a lupus anticoagulant. The patient was treated with warfarin, baby aspirin, and a calcium channel blocker and has not had a recurrence of permanent visual loss in 17 years.

Statin-induced myopathy prevented by creatine administration.

A 66-year-old woman with chronic myeloid leukaemia in nilotinib-induced remission was diagnosed with amaurosis fugax, caused by carotid stenosis. Serum cholesterol was 316 mg/dL (Low-Density Lipoprotein (LDL) cholesterol 213 mg/dL). Nilotinib was discontinued and replaced by interferon. Antiplatelet therapy and atorvastatin 40 mg/day were prescribed. Muscle pain and elevation of serum creatine kinase (CK) occurred; thus, atorvastatin was replaced by ezetimibe. Afterwards, muscle pain subsided and CK reverted to normal, but 2 years later serum cholesterol was still elevated at 218 mg/dL with LDL cholesterol 126 mg/dL. Simvastatin 5 mg/day was then started, but again muscle pain occurred and CK rose to 267 U/L. Simvastatin was stopped and serum cholesterol climbed to 252 mg/dL. Creatine was prescribed and simvastatin was reintroduced. Two months later, cholesterol was 171 mg/dL, CK was 72 U/L and there was no muscle pain. This case supports the view that creatine may prevent statin-induced myopathy.

Ocular migraine and antiphospholipid antibodies--where we stand?

There is no doubt that ocular migraine also known as retinal migraine or ophthalmic migraine should not to be confused with ophthalmoplegic migraine. The hallmark of ocular migraine is the unilateral visual loss or "monocular transient loss of vision" associated or followed by the headache. Better safe than sorry, therefore an ophthalmologic examination during the migraine attack is the most diagnostic method. age with typical history for ocular migraine. Importantly supportive data sustain that different neuro-ophthalmologic manifestations as amaurosis fugax, retinal vascular thrombosis and optic neuropathy, may be considered as the ocular hallmarks of the Hughes's syndrome. Clues for the evaluating of antiphospholipid antibodies include recurrent thrombosis especially in young people, recurrent fetal loss, and thrombocytopenia. There are no studies that focus exclusively on the prophylaxis of ocular migraine. Ocular features due to antiphospholipid antibodies - induced thrombosis or Hughes's syndrome should be treated with anticoagulant therapy.

Transient monocular blindness and the risk of vascular complications according to subtype: a prospective cohort study.

Patients with transient monocular blindness (TMB) can present with many different symptoms, and diagnosis is usually based on the history alone. In this study, we assessed the risk of vascular complications according to different characteristics of TMB. We prospectively studied 341 consecutive patients with TMB. All patients were interviewed by a single investigator with a standardized questionnaire; reported symptoms were classified into predefined categories. We performed Cox regression analyses with adjustment for baseline vascular risk factors. During a mean follow-up of 4.0 years, the primary outcome event of vascular death, stroke, myocardial infarction, or retinal infarction occurred in 60 patients (annual incidence 4.4 %, 95 % confidence interval (CI) 3.4-5.7). An ipsilateral ischemic stroke occurred in 14 patients; an ipsilateral retinal infarct in six. Characteristics of TMB independently associated with subsequent vascular events were: involvement of only the peripheral part of the visual field (hazard ratio (HR) 6.5, 95 % CI 3.0-14.1), constricting onset of loss of vision (HR 3.5, 95 % CI 1.0-12.1), downward onset of loss of vision (HR 1.9, 95 % CI 1.0-3.5), upward resolution of loss of vision (HR 2.0, 95 % CI 1.0-4.0), and the occurrence of more than three attacks (HR 1.7, 95 % CI 1.0-2.9). We could not identify characteristics of TMB that predicted a low risk of vascular complications. In conclusion, careful recording the features of the attack in patients with TMB can provide important information about the risk of future vascular events.

Do complaints of amaurosis fugax and blurred vision after transcatheter device closure of atrial septal defect indicate microemboli to retinal vessels?

Atrial septal defect (ASD) is a common diagnosis in adults undergoing surgical repair. The aim of the study was to determine if ocular symptoms following treatment are due to microemboli. The study group included 20 adult patients (9 men, 11 women, mean age 57.2 years) with ASD who had undergone successful closure with the Amplatzer occluder. Patients were treated with aspirin or warfarin during the 6 months after the procedure. All were evaluated neurologically and an ocular medical history was obtained. Ocular examination included the 120-point Humphery visual field. Transcranial Doppler (TCD) was performed to monitor the middle cerebral artery. Two patients complained of amaurosis fugax at 1 and 3 months after the procedure, and two patients complained of blurred vision at 3 and 4 months after the procedure. TCD performed within 24 h of the complaints revealed no abnormalities. In all patients, the neurological and ocular examinations, including the visual field test, were normal. In conclusion, microembolic events do not appear to be the cause of the ocular complaints in patients with ASD treated with Amplatzer occluder. Further studies in larger samples are needed to confirm these results.

[Fibrinolysis in the treatment of the amaurosis fugax: a case report]. / Fibrinolyse dans le traitement de l'amaurosis fugax. A propos d'un cas.

The authors report a case of amaurosis fugax treated first by systemic fibrinolysis and then by antiplatelet treatment. A 47-year-old suffering from transient amaurosis due to recurrent occlusion of retinal arterial branches improved after treatment and showed no recurrence. This protocol appears effective in cases of probable embolus in a young patient with no contraindications and when flow is not reestablished (amaurosis fugax), or when the required 6-hour time delay is respected.

Optic neuritis presenting with amaurosis fugax.

Optic neuritis usually presents with rapid and gradual loss of vision that is either complete or incomplete, and typically associated with retro-orbital pain. To our knowledge there have been no documented reports of optic neuritis presenting with multiple episodes of amaurosis fugax, the sudden and transient loss of vision lasting seconds to minutes. We report here the case of a young woman with a possible diagnosis of demyelinating left optic neuritis that presented solely with multiple episodes of brief and transient sudden loss of vision. Ophthalmological exams were normal between episodes of vision loss. The patient's magnetic resonance imaging of the brain showed a subtle enhancement of the left optic nerve along with multiple periventricular lesions, highly suggestive of a demyelinating disease. The frequent episodes of visual loss resolved completely with high dose parenteral steroids. Neurologists and other clinicians should be aware of this unusual presentation of optic neuritis as treatment modalities differ greatly from other causes of amaurosis fugax.

Rare manifestations of Churg-Strauss syndrome: coronary artery vasospasm, temporal artery vasculitis, and reversible monocular blindness-a case report.

Churg-Strauss syndrome (CSS) is a rare illness with clinical findings characterized by asthma, eosinophilia, and vasculitis affecting medium and small-sized arteries and veins in a variety of organs. Involvement of the temporal arteries by non-giant cell eosinophilic vasculitis in CSS is quite rare and has only been published as isolated case reports or small patient series. Myocardial infarction due to coronary artery vasospasm is an unusual manifestation of CSS. We describe a case of a 39-year-old woman who had two myocardial infarctions due to severe coronary artery vasospasm and was diagnosed with CSS based on a temporal artery biopsy. During the course of her treatment, she also had another rare manifestation of CSS, monocular blindness reversible with immunosuppressive therapy.

[Amaurosis fugax: case report]. / Amaurosis fugax? Opis przypadku.

We describe the case of 27-year-old woman with systemic lupus erythematosus (SLE) and the presence of anticardiolipin antibodies (aCL) IgG isotype in high titre in the plasma, who reported sudden loss of vision in both eyes. We established diagnosis of acute optic neuropathy probably associated with aCL and SLE flare. Treatment with anticoagulation, high dose steroids and intravenous cyclophosphamide was followed by improvement of the visual function.

A case of frequently recurring amaurosis fugax with atherothrombotic ophthalmic artery occlusion.

A 49-year-old woman with diabetes mellitus and hyperlipidemia experienced frequent transient monocular blindness in the right eye during a 3-week period. Examination revealed atherothrombotic occlusion of the right ophthalmic artery (OA) without embolic sources. After treatment with aspirin, attacks resolved completely. Her symptoms were attributed to microembolism from the occluded OA.